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Employers Take Heed – Agencies Issue Letter Warning of Impending Enforcement Actions on Contraceptive Coverage Mandate

On the heels of even more complaints from employees about health plan noncompliance with the contraceptive coverage mandate, the Secretaries of the DOL, HHS, and IRS issued a joint letter warning plan sponsors and health carriers that they “may take enforcement or other corrective actions as appropriate.”

As a reminder, the Affordable Care Act contraceptive coverage mandate requires non-grandfathered group health plans and carriers to cover, without cost-sharing, preventative care and screenings. Plans and carriers must cover without cost sharing at least one form of contraception in each contraceptive category. The plan must also cover all contraceptive services or FDA-approved contraceptive products an individual and their medical provider have determined to be medically appropriate.

The letter urges plans and carriers to “immediately ensure” they are compliant to avoid future enforcement actions. Recommended steps include:

  • Developing an easily accessible, transparent, and expedient exceptions process for contraceptive products if one is not already in place
  • Reviewing exceptions to processes for contraceptive products to ensure that they are easily accessible, transparent and expedient, and not unduly burdensome on the individual or provider
  • Developing and using a standard form and instructions for the exceptions process and suggesting the Medicare Part D Coverage Determination Request Form as a model if the plan does not currently have a standard form
  • Ensuring information about the availability of and instructions for the exception process, including standard forms, are described to individuals and their providers in plan documentation and online resources
  • Deferring to a provider’s recommendation regarding contraceptive products based on a determination of medical necessity
  • Eliminating overly burdensome, inappropriate, and unreasonable medical management techniques

Next Steps

Because of the changing complexity of state laws, employers are encouraged to check their plan documents with their Benefits Consultant and health plan providers to ensure they are complying with the ACA’s contraceptive coverage mandate.

As you navigate the implications for your employees, learn how your health plan may be impacted by the Dobbs v. Jackson decision in the on-demand event: Employer Considerations in Light of Dobbs Decision.